Form

Has this pregnancy center received 501(c)(3) tax exempt status from the IRS?*

Yes

Pending

If pending, date applied to the IRS: *

If no, please explain:

Operation Status

Date Opened:

Proposed Open Date:

Location Type

Main Center

If applicable, please put the number of branch locations:

Mobile Ultrasound Unit ONLY

Physical Address

Physical City*

Physical State/Province*

Physical Zip/Postal*

Mailing Address

Mailing City*

Mailing State/Province*

Mailing Zip/Postal*

Center Contact Information

Business Phone*

Business Email*

Donor/Supporter Email*

Donor/Supporter Website

Client Phone*

Client Email*

Client Website

Does your client website have a disclaimer?*

Yes

Employment Information

Name of Director*

Director's Email*

Director's Direct Phone Number*

Volunteer or Paid*

Volunteer

Paid

If paid, date hired:

Hours worked per week:*

Are all paid staff compensated according to applicable federal, state, and local labor laws?*

Yes

Approximate annual income of the pregnancy center?*

How is the organization insured?*

General Liability

Professional Liability

Business Auto (for Mobile Ultrasound Units)

Please provide the information where applicable:

Name of General Liability Provider:

Name of Professional Liability Provider:

Name of Business Auto Provider:

Center Services Information

Days & Hours of Operation:

Monday Client Service Hours (put CLOSED, if closed)*

Tuesday Client Service Hours (put CLOSED, if closed)*

Wednesday Client Service Hours (put CLOSED, if closed)*

Thursday Client Service Hours (put CLOSED, if closed)*

Friday Client Service Hours (put CLOSED, if closed)*

Saturday Client Service Hours (put CLOSED, if closed)*

Sunday Client Service Hours (put CLOSED, if closed)*

Total operating hours per week:*

Other Support Services

Pregnancy Test Procedures:

How are pregnancy tests administered?*

Self-administered by clients

Administered by medical staff

If other, please explain:

Does the center have a Clinical Laboratory Improvement Act (CLIA) waiver?*

Yes

Does the Pregnancy Center offer Medical Services? *

Yes

Medical Services:

If yes, what medical services are provided?

Ultrasounds (Onsite)

Ultrasounds (Mobile)

STD/I Tests

STD/I Treatments

Other Medical Services:

Does the center offer medical services under the direction of a licensed physician who is in good standing within the state where the center is located?*

Yes

Are all medical services, including ultrasound services, only provided by trained medical professionals?*

Yes

Does the center carry medical malpractice insurance?*

Yes

Mission and Vision:

Please write you center's mission statement: *

Please write your center's vision statement:*

Board Information

Board Chair Name*

Board Chair Occupation*

Board Chair Phone Number*

Board Chair Email*

When did the Board Chair come onto the board (year)?*

Vice Chair Name

Vice Chair Occupation

Vice Chair Phone Number

Vice Chair Email

When did the Vice Chair come on to the board (year)?

Secretary Name

Secretary Occupation

Secretary Phone Number

Secretary Email

When did the Secretary come on to the board (year)?

Treasurer Name

Treasurer Occupation

Treasurer Phone Number

Treasurer Email

When did the Treasurer join the board?

Board Member Name

Board Member Occupation

Board Member Phone Number

Board Member Email

When did this Board Member join the board (year)?

Board Member Name

Board Member Occupation

Board Member Phone Number

Board Member Email

When did this Board Member join the board?

Please upload remaining board information here is needed.

Other Affiliations

Affiliated with the following organizations:

Please list other affiliated organizations below:

Affiliation Agreement

Please upload signed Affiliation Agreement here:

Affiliation Agreement*

For Developing Centers Only

For centers that have not yet opened to clients, or have been opened for less than 12 months, please upload a copies of the following with the application:

Care Net Affiliate Application